Catching up with questions and comments

I wanted to just reply to a few comments and questions that have appeared here and on Twitter. I’m very gratified that so many people have clearly been thinking about this stuff.

I think we can and should generalise what I said about ski helmets to just about any realm of activity where they are “counted on” to provide protection. Construction hard-hats, bicycle helmets, hockey, Formula 1 pit crews, etc. The injury patterns almost certainly are different in each endeavour, and each therefore probably needs a different helmet. In general, we can’t expect the end user to do anything except have confidence in the equipment he (or she, that’s assumed in all my blog posts) chooses to use, or is obliged to use. That means that those who supply those helmets need to have a good idea of exactly what sort of injuries they need to mitigate. Clearly access to an appropriate level of protection has to be monetarily feasible. I chuckle to hear national-level rally drivers complain about a €2000 helmet (before going out and spending more than that on a set of tires! Helmets don’t make you fast!). I assume that a top of the line ski suit costs at least €800-1200. So that’s a constraint within which the manufacterers will have to work. They’re smart people. They’ll figure it out if the data gets generated.

Measuring g’s at the helmet with accelerometers is interesting, but there are severe enough problems with coupling to the head to make this data almost unusable in terms of BRAIN g’s. The DoD, and the FIA Institute, have been working on earpiece accelerometers for some time. These incorporate tiny 1 x 1 x 1 mm triaxial accelerometers into the part deepest into the ear canal. While this should theoretically give robust values for BRAIN g’s, that’s not happened yet. IRL has used earpiece accels for a while now, but I’m not sure they’re generating clinically useful data . . . yet.

Several people have sent me clippings concerning the effects of fish oil. Apparently someone “woke up” a comatose child using mega doses of fish oil. The explanations given were something like, well the brain is made up of fats, and so we give this good fat and it’s anti inflammatory too. The problem is that the person who administered this treatment published his results . . . on CNN. He should have published them in a peer-reviewed journal. Call me old-fashioned, but in terms of TREATING (not experimenting on) human beings, good quality evidence is the way to be guided, not what you saw last night on Dr. Sanjay Gupta’s show. That said, were I to be the close relative of a comatose head trauma patient, and were i to be  convinced that the risk profile of this kind of use of fish oil was acceptable, it is entirely possible that I’d be willing to have a go. But at the moment, let’s be clear, this is closer to ritual incantation than to medical science.

Lastly, something that’s been bothering me. A lot. As a doctor who practices pre-hospital medicine regularly.

Here goes: why was Michael brought to the hospital at Moutiers initially, and not to a neurosurgical centre? I am not trying to second guess (ok, just a bit) my colleagues who landed there on the 29th of December . . . BUT

  • reliable witnesses report to you that the victim hit his head
  • the victim’s helmet has been damaged in the impact
  • there’s blood on the snow
  • there is obvious signs of an open head injury
  • the victim is agitated (in any event his behaviour is not ENTIRELY normal)

Now I’m sorry, but it doesn’t take a doctor to put this together and figure out, “hey this person may have a head injury”.

Thing is, it is a general principle of pre-hospital medicine to take a patient to the closest APPROPRIATE facility. In a given Emergency Medical System’s territory, if this is applied “conservatively” it pretty much ALWAYS includes, for example paediatric cases and potential head injury. Thing is, there’s no neurosurgery at Moutiers. Why then was Michael brought there?

This question needs to be answered. As devastating as the injuries produced directly by the fall are, any delay in proper airway control and neurosurgical intervention cause further damage and must be minimised.

I raise this point simply because local protocols should be reviewed, and adjusted appropriately, in order to optimise the time it takes to get head-injured skiers cared for appropriately.

24 thoughts on “Catching up with questions and comments

  1. I think that everyone should be as hopeful and positive as possible. Negativity doesn’t help anyone, and I think it is important for his family to know that people haven’t given up hope. I certainly haven’t. I think that his wife is an absolute angel who is doing everything possible to keep upbeat about her Husband’s progress, and all this negativity is not good for his family or anyone else. As long as Michael Schumacher is still alive, there is still hope for recovery, and on that basis alone my fingers are firmly crossed that he will recover, even if his life changes drastically, life is precious and he will still have his friends and most importantly his family to help support him in future. Good luck Michael, we are all routing for you🙂

  2. Michael him self made him what he is, not the fans. He still is a hero in my life, but that does not mean, that us, fans, have any right what so ever, to be included in his treatment, with the info of progress, the ups and downs of the treatment, or how many times did he blinked, moved his lips and so on. And i am a big fan of his. I cryed when it happend. But there is the line then. We love him, we miss him, we are sad for him, but all the rest, is his private life. There is his family and friends who are something that he needs. He does not need our demands to be informed. What is there to know anyway? He is hurt badley and some of the best brain surgens and specialist are doing their best to save him. All we can do is pray and LEAVE HIM AND HIS FAMILY ALONE! IN PEACE! What is wrong with you people?

  3. I read today that Martin Donnelly was in an induced coma for 6 (nearly 7) weeks. Very different medical circumstances (his body was broken, not his brain) but seems to indicate that the length of Michael’s induced coma is maybe not that unusual. But I also read that Michael was already in a coma when he was admitted to Grenoble. If that is the case is the word ‘induced’ misleading?

  4. Hi Doc the information I could gather states
    11:07 call from a skier received, Rescue on site 10 min later.
    11:30 Helicopter takes off heading to Moutiers Hospital
    12:40 MSC arrives in Grenoble CHU
    Checking again all these news I noticed something that I didn’t pay attention to on the day…
    It looks like MSC was conscient when taken into the helicopter. “Il était mi assis, mi debout et faisait de grands gestes agités, m’ont-ils rapporté.» Ils ont vu qu’il avait un choc à la tête et ont immédiatement appelé l’hélicoptère.”
    http://www.ledauphine.com/france-monde/2013/12/31/le-temoignage-des-pisteurs

  5. Doc,
    you have an amazing way of conveying the important info in a real world way. Thank you so much for your time and effort in keeping us up to date with the best available data and interpretations of that data.
    Cheers,
    Steve

  6. Dr. Hartstein,

    I really share your opinion. ( I was talking about that this afternoon with one of my relatives) : a big shock on the head, an helmet broken into three parts, blood on the snow, blood on a rock, agitation if not a kind of convulsions : I’m not a Doctor at all but all these facts would have made me think that it must have been very a very serious injury (of the head of course) and that the victim should have been examined by specialists as soon as possible (in order to stop a possible negative evolution)…

  7. Remember how fortunate it was that Robert Kubica had his huge accident very close to the specialist hospital at Santa Corona, allowing his ‘bits’ to be put back together by experts very quickly, and at least without intermediate interventions.

  8. Thank you for this information. Much of the news is speculation so it is nice to have possible possibilities clearly and rationally laid out. After following F1 for 24 odd years Michael is a driver who has entertained extremely well. I have shouted both against him (in the Hill V Schumacher days) and for him. I would not wish this on anyone, but feel I must follow his recovery- almost as a way of saying thank you for years of Sunday track excitement. I am checking news daily. I hope his wife and family are being given support, as it will be a very hard road they will have to travel, and my thoughts go out to them. Once again thank you, and Thank you Michael for everything you were, and hope will be again.

  9. Michael has been talking to his personal angel and God since accident. It seems that his life is over now in this world, but there is no fear, he will be alive still as we human souls will. Sad but he is just stepping on another world after a amazing life on here. Hugs to his family,

    • Wow, you must have some “real” insight into his condition and certainty! Thank you for sharing your knowledge and ethereal drivel with us. I found it so positive and uplifting with just the right amount of pretentiousness.

  10. Hello Dr. Hartstein
    My thoughts are often with Michael and his family and I regularly look for hopeful updates on his condition; one must never give up hope. As a carer of someone who suffered a brain injury, and family members who have other neurological problems such as epilepsy and brain tumour, I do feel for everyone involved in Michael’s care. What happened to him is a life changing situation for all concerned and they will need time to come to terms with things and adjust to their new ‘normal’ (that’s what we call it and how we coped with the change anyway). I enjoy your blog posts and respect your viewpoint as a Medical Practitioner; thank you.
    Lesley.

  11. Pingback: Räddningsarbetet vid Schumachers olycka får skarp kritik | Anders Formula1

  12. When I asked you several days ago about the Omega 3 oil, that was really my question; did it have any legitimacy in trials or research. Thanks for the expounded answer. I, too, questioned the stop at the first hospital as I read in at least one report that the helicopter had to land so Michael could be intubated and arrived in a comatose state. If I remember correctly, he spent the entire “golden hour” at Moutiers. I would have thought Moutiers would have instructed them in air to continue non-stop to Grenoble after hearing condition at accident scene and if he had problems in route. But hey, I’m not a doctor so what do I know…

  13. Hi Doc,

    Does the stop in Moutiers really matters?
    I mean, had they gone directly to Grenoble and save 45 min to 1h, would the patient’s situation, as it is today, been different? Knowing now, AFTER the facts, what the damages were and with what we know so far, ICP would have still risen dramatically and they would have operated and evacuated the hematoma the same way, just an hour earlier. Would this be of a significant difference? I do not know how quickly brain hematoma swell and how quickly ICP builds up.

    I recall reading somewhere that the stop in Moutiers was to refuel the helicopter. That as they airlifted him from Meribel, they assessed the situation and decided that Grenoble was the best call, however, however they needed more fuel. I do not know if this a true fact or some journalists extrapolation but I remember reading it. I dont know if we was actually admitted in Moutiers or not. If that’s the case, we’re only talking a few minutes.

    Thanks

  14. Hi Gary, thanks once again for these comments. The friend of mine that I mentioned earlier who had motorbike accident & lay in induced coma for about 6/7 weeks was in a similar predicament where they had a choice of hospitals. His injuries were to his chest & they chose the hospital that specialised in liver surgery. That choice saved his life.

  15. Hi Gary, if Michael continues to remain in a coma, bearing in mind that his wife and children are not in their hometown or near where they live, can Michael be moved to another hospital to enable his family to be closer to home, so they can then be at home and the children can go to school etc, or is it best for the patient to remain where he is. Also if Michael were to remain in a coma for the rest of his life, are there specialist clinic’s or nursing homes for people like Michael where they can be cared for rather than being in a hospital? Thank you. Linda

    • Yes – medical repatriation is quite common. Once things have stopped changing/the need for constant monitoring has passed, he could be cared for at home, even, if the correct resources are available. If he regains any kind of consciousness, it is likely in his best interests to be in a normal home environment with his family.

  16. Dr. Hartstein,
    Your post about pre-hospital treatment brings to mind questions about pre-hospital treatment of Diana Spencer and Dodi Fayed in 2007. The French Emergency Medical authority had a policy of en route intervention (even stopping transport) versus the “grab and go” policy which aims to preserve as much of the “golden hour” as possible. Isn’t it time for international consensus on treatment of trauma? IMO, It seems the French system is out of step with modern standard of care.

    • Needless to say we french do believe our system is fine. The SMUR/SAMU has got the proper Doc (urgentistes) on board and the equipment to go with it. However this is not the place to discuss about it.

  17. Excellent article again Gary. Do you think if a similar injury occurred in F1 that they would be taken to the best place? I certainly think so.

    I read in Fabrice Muamba’s book how they took him to the London Chest Hospital because of their cath lab. It wasn’t the nearest place but it was the best one. I do believe if he was in his own home he wouldn’t have made it because of the experts he could get to his side.

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